Has chic become sickly?

Suddenly, models are being banned for being too thin. Health experts say it's a chance to end the "crusade of thinness."

By LISA GREENE, Times Staff Writer
Published October 8, 2006

The fashion models who stroll down runways in couture gowns are supposed to embody the height of style. But some are turning heads for a different reason: They look as if they weigh less than the clothes they're wearing.

The recent decision to ban underweight models from Madrid's fashion week set off a buzz about the images the fashion industry presents to the world as ideal. Everyone has an opinion, it seems, about whether the models are just naturally skinny or walking ads for eating disorders. The cover story in Monday's edition of People magazine talks about the ban, with waif-like actors such as Kate Bosworth and Nicole Richie thrown in.

"PRESSURE TO BE THIN," the headline blares.

So how thin is too thin? At what point does skinny become unhealthy?

The answer is a little different for everyone. Some people really are naturally slim. But being too thin can hurt their health even if they are modestly underweight, rather than at the point of having an extreme eating disorder, doctors say.

"Some of them probably don't have anorexia," said Dr. Pauline Powers, a professor of psychiatry and behavioral medicine at the University of South Florida College of Medicine and also immediate past president of the National Eating Disorders Association. "But still and all, they're underweight, and might be hurting themselves even if they don't have anorexia."

The health effects of being underweight start out minor, such as catching cold more easily and taking longer for cuts to heal. They can get more serious, especially for women: thinning bones and trouble getting or staying pregnant. And they can become deadly: kidney failure, heart disease, cardiac arrest.

Madrid fashion organizers based their decision on body mass index, a common measure that is a ratio of height-to-weight. Most often, BMI is used as a measure of the obesity epidemic: 25 and over is considered overweight, 30 and over obese.

This time, fashion looked at the other end: Below 18.5 is considered underweight. Models with a BMI under 18 were booted from the Madrid show.

How skinny is that? A 5-foot-11 model weighing 129 pounds or less couldn't walk the runway. The average American fashion model is 5-foot-11 and weighs 117 pounds, according to the National Eating Disorders Association.

By comparison, the average American woman is 5-foot-4, weighs 163 pounds and is overweight, with a BMI of 28.

The range of a healthy BMI, 18.5 to 24.9, is more than just a number. It's the range where people are least likely to be sick or die. Above - and below - the range, the risk goes up.

"It's not this magical thing that as soon as you cross that number, bad things happen," said Laura Kettel Khan, deputy chief for chronic disease nutrition at the federal Centers for Disease Control and Prevention. "To be that thin, for the most part, you're not consuming enough food to meet your nutrient requirements."

Those who are underweight probably also aren't taking in enough fat and protein, Khan said. Without enough protein, it's hard for the body to rebuild muscle and other tissues. That's why people may develop skin problems and wounds that take longer to heal.

They also may have less energy and think less clearly.

"Those are the preliminary things in a cascade of events," Khan said.

Women, who are most at risk of becoming severely underweight, can develop what sports medicine specialists call the "female athlete triad."

Some physically active women may stop eating enough, even if the problem isn't severe enough to be labeled anorexia. They may stop menstruating. As their estrogen levels drop, they may lose bone mass.

If people develop a full-fledged eating disorder, anorexia or bulimia, they can suffer damage to their heart, liver or kidneys.

They can suffer chemical imbalances that lead to cardiac arrest - the reason suspected for the attack that led to Terri Schiavo's vegetative state.

Concerns go beyond the health of the models themselves. Advocates worry about what the constant barrage of thinness does to the self-image of young women and girls.

Restrictions have been placed on tobacco and alcohol advertising, said Lynn Grefe, CEO of the National Eating Disorders Association.

"Yet we're letting this crusade of thinness just slip right by us," said Grefe.

Media images don't cause eating disorders, experts agree.

"It has an effect, but there's a lot more to anorexia than that," Powers said.

But they also worry that, as girls develop distorted ideas of what they should look like, such images can trigger unhealthy eating habits that might eventually lead to an eating disorder.